Notice of Child and Family Counseling Center (CFCC) Policies and Practices to Protect the Privacy of Your Health Information

HIPPA Notice

Overview

This notice provides you with information about how your mental health records at CFCC may be used, the rights you have as a patient, and our legal duties as providers of treatment. We are required to provide you with this notice under the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule, which takes effect on April 14, 2003. This law is designed to protect the confidentiality of your treatment and records created as part of your treatment. Please review it carefully. Let us know if you have any questions or would like additional information. If you do not sign this consent form agreeing to what is in this notice, we cannot treat you.

I. Uses and Disclosures for Treatment, Payment, and Health Care Operations

As part of your treatment, we (your therapist or any staff member at CFCC acting on your behalf) will record, maintain, and use individually identifiable health care information about you. This may include information describing your history, symptoms, test results, diagnoses, treatment, treatment plan, billing, and health insurance information.

We may disclose your protected health information (PHI) for treatment, payment, and health care operations purposes with your consent. Treatment is when we provide or coordinate your health care. An example of treatment would be when your therapist consults with another health care provider, such as your family physician or another therapist.

Your PHI may be disclosed in order to collect payment for services provided or to determine eligibility or coverage.

Health Care Operations are activities that relate to the performance and operation of our practice. Examples of health care operations include quality assessment and improvement activities, business-related matters such as audits and administrative services, care coordination, accreditation, certification, licensing or credentialing activities.

II. Uses and Disclosures Requiring Authorization

We will not use or disclose your medical information for any reason except those described in this Notice without your written consent. We may use or disclose PHI for purposes outside of treatment, payment, and health care operations when your appropriate written authorization is obtained.

We will also need to obtain a separate authorization before releasing your psychotherapy notes. Psychotherapy notes are notes that your therapist writes made about your conversations during a private, group, joint, or family counseling sessions, which your therapist keeps separate from the rest of your medical record. These notes are given a greater degree of protection than other PHI.

You have a right to refuse to authorize releasing your information to others, with certain exceptions which are listed below. You may revoke all such authorizations at any time, provided each revocation is in writing, but this will not affect prior authorized uses or disclosures.

Given the significant risks in faxing confidential patient information, we will no longer fax such information to workplaces and schools. We recognize that this is an inconvenience and ask that you give us as much advance notice as possible so that we can mail information to you or to others as you request.

III. Uses and Disclosures with Neither Consent nor Authorization

We may use or disclose PHI without your consent or authorization in the following circumstances, as required by state and Federal law:

* Healthcare Operations: If you request that we submit bills to an insurance company for payment, you are deemed to have consented to the disclosure of specific information, including dates of service, name, policy number, diagnosis, services offered, prognosis, progress, medications prescribed, and the patient's relationship to the subscriber of the insurance. Only the minimum information necessary to obtain reimbursement will be provided.

* Child Abuse: If we have reason to suspect that a child is abused or neglected, we are required by law to report the matter immediately to the Virginia Department of Social Services. We will discuss this with you as appropriate.

* Abuse of Elderly or Incapacitated Adults. When we have reason to suspect that an incapacitated adult (e.g. someone who is not able to advocate for himself or herself) is being abused, neglected or exploited, we are required by law to make a report and provide relevant information to the Virginia Department of Social Services. You will be notified of this action unless your therapist believes that it would put you at risk of serious harm.

* Health Oversight: The Virginia Board of Health Professions, including the Boards of Medicine, Psychology, Social Work, and Counseling, has the power to subpoena relevant records should we be the focus of an inquiry.

* Judicial or Administrative Proceedings (Court Orders): If you are involved in a court proceeding and a request is made for information about your treatment, we will not release information without your written authorization. If we receive a subpoena for your records (of which you have been served, along with the proper notice required by state law), we are required to respond. We will attempt to contact you first to see if you consent to such release. If you object, you may file a motion with the clerk of the court to move to quash (block) the subpoena. Notify your therapist as soon as possible; we are then required to place your records in a sealed envelope and provide them to the clerk of the court so that the court can determine whether the records should be released.

* Serious Threat to Health or Safety of Others: If you communicate to us a specific and immediate threat to cause serious bodily injury or death to an identified or to a readily identifiable person, and we believe you have the intent and ability to carry out that threat immediately or imminently, we must take steps to protect the threatened person.

* Danger to Self: Your therapist can break confidentiality if you (or your child) are in danger of hurting yourself, in order to keep you (or your child) safe. This may include notifying emergency personnel.

* Worker's Compensation: If you file a worker's compensation claim, we are required by law, upon request, to submit your relevant PHI to you, your employer, the insurer, or a certified rehabilitation provider.

* Supervision: Your therapist may discuss your treatment with colleagues to improve the quality of your care. However, your name or other identifying information that could identify you will not be used.

* Debt Collection: Your name can be reported to a collection agency and/or a credit bureau if you fail to pay your bill. You will be notified before such a report is made.

* Legal Defense: Disclosure may be made if a therapist must arrange for legal consultation if a patient takes legal action against a therapist.

* Quality Assurance: If you are using insurance to pay for part or all of your treatment, an insurance company can periodically review records to insure quality care.

IV. Patient's Rights

· Right to Request Restrictions -You have the right to request restrictions on certain uses and disclosures of protected health information about you. However, we are not required to agree to a restriction you request.

· Right to Receive Confidential Communications by Alternative Means and at Alternative Locations - You have the right to request and receive confidential communications of PHI by alternative means and at alternative locations. For example, we can send your bills to an address other than your home if you request this.

· Right to Inspect Records - You have the right to inspect your records, including PHI and billing records for as long as the PHI is maintained in the record. We generally keep records for five years after your last visit here. Because these are professional records, they can be misinterpreted and/or upsetting to untrained readers. For this reason, we require that you initially review them with your therapist or have them forwarded to another mental health professional so you can discuss the contents. We may deny your access to PHI and psychotherapy notes, but in some cases you may have this decision reviewed. One reason for denial is if your therapist believes that releasing such information would likely cause substantial harm to you (or your child if your child is the patient). On your request, we will discuss with you the details of the request and denial process.

· Right to Amend - You have the right to request an amendment of PHI for as long as the PHI is maintained in the record. We may deny your request; if so, we will provide you with a written explanation.

· Right to an Accounting - You generally have the right to receive an accounting of disclosures of PHI for which you have neither provided consent nor authorization (as described in Section III of this Notice). We must provide you with the accounting within 60 days of your written request.

· Right to a Paper Copy - You have the right to request a copy of the CFCC Privacy Policy from us.

V. Privacy Safeguards

CFCC has developed appropriate administrative, technical, and physical safeguards to protect the privacy of your Protected Health Information. These including placing locks on file cabinets, shredding documents with identifying information, using passwords on computers, as well as other safeguards. We also have policies in place with regard to our dictation service, answering services, and file shredding service.

VII. Uses and Disclosures Involving Personal Representatives

Where an incapacitated patient has a guardian or legal representative with authority to make health care decisions for the patient, we must treat the guardian or legal representative as the patient with respect to PHI. If the patient is a minor child, the therapist must treat the parent (or legal guardian) as the patient with respect to PHI. However, if the therapist has reasonable belief that a parent, guardian, or legal representative has subjected or may subject the patient to abuse or neglect or otherwise endanger the patient, and believes that it is not in the patient's best interest to release such information, the therapist may elect not to treat the parent or guardian as the patient and hence not disclose confidential information. A parent or guardian may allow a confidentiality agreement between the minor patient and the therapist.

VIII. Complaints

If you are concerned that we have violated your privacy rights, or you disagree with a decision made about access to your records, you may contact our HIPAA Privacy Officer, James J. Crist, Ph.D., to register a complaint or to obtain further information. A form to make the complaint will be provided upon request. You may also send a written complaint to the Secretary of the U.S. Department of Health and Human Services. We will not retaliate if you file a complaint.

VI. Effective Date, Restrictions and Changes to Privacy Policy

This notice will go into effect on April 14, 2003. We may revise our privacy policies, as permitted or required by law. These revisions, which may be retroactive, will apply to all PHI that we maintain. We will provide you with a revised notice.